Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0035, written 21 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Jan 2025 |
|---|---|
| Reference | 2025-0035 |
| Deceased | Carl Butler and Sean Brett |
| Coroner | John Gittins |
| Coroner area | North Wales (East and Central) |
| Category | Road (Highways Safety) related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
John Adrian Gittins Senior Coroner for North Wales (East and Central) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Cheshire Constabulary Clemonds Hey, Oakmere Road, Winsford CW7 2UA 1 CORONER I am John Adrian Gittins, Senior Coroner for North Wales (East and Central) 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On the 28th of February 2022 I commenced investigations into the deaths of Carl Anthony Butler (DOB 19.10.67 DOD 26.02,22) and Sean Brett (DOB 03.01.72 DOD 26.02.22) . The investigations concluded at the end of the inquest on the 17th of January 2025. In relation to both deaths, I returned narrative conclusions as follows: For Mr Butler – On the 26th of February 2022 whilst intoxicated, the deceased drove his vehicle in the wrong direction along the A55 at Broughton and into collision with an oncoming vehicle, sustaining unsurvivable injuries, and as a result he was verified dead at the scene. For Mr Brett - On the 26th of February 2022 on the A55 at Broughton, the deceased was the driver of a motor vehicle which was struck by another vehicle which was being driven in the wrong direction on the carriageway by a person who was over the prescribed drink driving limit. As a result of the collision Sean Brett sustained injuries which were incompatible with life and was declared deceased at the scene. 4 CIRCUMSTANCES OF THE DEATH On the 12th of February 2022, Carl Butler had been arrested, charged and bailed by Cheshire Constabulary in relation to a drink-drive offence. At approximately 05.15 on the 26th of February 2022, Cheshire Constabulary received report of an intoxicated driver leaving a petrol station in Chester. (This was Mr Carl Butler driving a vehicle registered to him). A report was put out requesting observations for this vehicle but the car and driver were not located. At approximately 11.45 the same day, Cheshire Constabulary received a further report in relation to this vehicle and to the erratic manner in which it was being driven. Around 30 mins later, Mr Butler drove his car the wrong way along the A55 dual carriageway, colliding with Mr Brett’s’ vehicle coming in the opposite direction, resulting in both their deaths. Subsequent tests established that Mr Butler was more than four and a half times the prescribed drink drive limit at the time of the collision. Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 | 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – 1. There was a confused picture of the management of the reports and information being handled by Cheshire Police insofar as a request for observations would be put out to officers by a communications operator, however there was no requirement for any officer to acknowledge that they had received such a request and therefore no means by which it could be confirmed that any actions were being undertaken as a result of the reports which had been received. 2. There was also confusion within the control room as to the methodology by which a vehicle could be added to an ANPR/Vehicle Finder System, and although an IOPC investigation was finalised in February 2023 which identified potential learning for the force in respect of ensuring control room staff understand the appropriate processes, evidence was heard at the inquest that a witness had not received this training until December 2024 due to a lack of time being made available to her to undertake the same. (Where learning identifies required training/actions, any delays in delivering this, can only serve to perpetuate the risks which such training/actions is aimed at mitigating.) 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 18th of March 2025 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Families of the Deceased and to the Chief Coroner. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated 21st January 2025 Signature Senior Coroner for North Wales (East and Central) Coroner's Office, County Hall, Wynnstay Road, Ruthin, LL15 1YN Tel 01824 708047 |
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
OFFICIAL S28 Response to John Adrian Gittins, Senior Coroner for North Wales (East and Central) Matters of concern raised within the S28 Response Point 1 There was a confused picture of the management of the reports and information being handled by Cheshire Police insofar as a request for observations would be put out to officers by a communications operator, however there was no requirement for any officer to acknowledge that they had received such a request and therefore no means by which it could be confirmed that any actions were being undertaken as a result of the reports which had been received. Response Cheshire Constabulary has reviewed the way in which reports of dangerous driving / drivers are processed. As part of that change, all communications operators who work within the resource deployment centre (RDC) and all operational officers will receive new guidance as a direct result of the learning from investigation into the deaths of Mr Butler and Mr Brett on 26th February 2022: Part of the that guidance is the requirement for communications operators to make clear and sustained attempts to confirm that an appropriate patrol acknowledges their radio transmissions regarding observations for drivers or vehicles that pose a risk to the public. These attempts must continue until it is established that there is either such a patrol available to be assigned, or that there are no patrols available immediately in the relevant location. Once these facts are established, the call sign of the patrol assigned must be recorded in line with current practices, with the addition of the patrol’s location and their direction of travel. The incident log will be updated to reflect the fact that there are no available patrols and where appropriate, this will be escalated to the Force Incident Sergeant for them to consider deploying a patrol from another geographic location or force. The practice of operators stating or recording the words ‘nothing heard’ (or similar) in response to any request for an available patrol that is unanswered will cease, and officers will be required to respond over the air. OR Point 2 There was also confusion within the control room as to the methodology by which a vehicle could be added to an ANPR/Vehicle Finder System, and although an IOPC investigation was finalised in February 2023 which identified potential learning for the force in respect of ensuring control room staff understand the appropriate processes, evidence was heard at the inquest that a 1 OFFICIAL witness had not received this training until December 2024 due to a lack of time being made available to her to undertake the same. (Where learning identifies required training/actions, any delays in delivering this, can only serve to perpetuate the risks which such training/actions is aimed at mitigating.) Response In court, communications operator Natalia Komorowska stated that she had not received her training until December 2024. Natalia has clarified that she was referring to refresher training and Constabulary training records show that she had received her initial training in March 2021, and she was confirmed as being a competent deployment operator in October 2021. In December 2024 Natalia received a refresher of the foundation and dispatcher NCALTS training. All communications operators who currently work within the resource deployment centre have attended a specific course which includes ANPR, Hotlist (Cleartone) and Vehicle Finder. There is also ongoing continued professional development plan in which all operators (including call taking function) will be required to repeat refresher training. Additional support will be provided by the ANPR coordinator. 2
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